April 4. To cash received from Westmoreland Co. Med. Soc., for dues of 1877 $15 00 27 00 June 14. By cash paid Dr. R. L. Sibbett, Chairman "Committee on Medi 66 46 20. 66 66 T. K. Collins, for printing, etc., Transactions of for expenses of Committee on State B'd of Health The following County Society is in arrears:— Columbia County Society for dues of 1877 PITTSBURG, May 20, 1878. 200 00 8 35 37 82 15 73 897 03 $2637 41 $18 00 ADDRESS IN OBSTETRICS. BY WILLIAM GOODELL, A.M., M.D., CLINICAL PROFESSOR OF GYNECOLOGY IN THE UNIVERSITY OF PENNSYLVANIA. GENTLEMEN: IN these halcyon days of Abstracts, Retrospects, and of bookclubs, it seems to me a thankless task to jot down the annual snailpace progress of any given branch of medicine. I have, therefore, ventured to narrow down the Address in Obstetrics, with which you have kindly honored me, to a single subject-that of Laceration of the Cervix Uteri. This subject I have chosen, not because it is new, nor because it is one in which there is much room for original work, for my friend, Dr. T. A. Emmet, has written pretty much all that can be said about it; but because it is one the importance of which is too little recognized by my brothers in this State, and I thought that the experience of one of their own number would perhaps serve to call their attention to it. The cervix uteri often gives way during labor, far more frequently than it ought, far more frequently, indeed, than it would, were nature oftener allowed to take the lead. In these busy days there is unfortunately a tendency to urge on labor, more, I fear, for the sake of the physician than for that of his patient. The means used for this purpose are, the early rupture of the membranes, the administration of ergot, the resort to the forceps before the os uteri has become dilatable, and the efforts made to push up the thinnedout cervix over the presenting part. Now these means hasten the passage of the head through the os uteri, and consequently they are fraught with danger to the integrity of the cervix. Among them the early breaking of the bag of waters takes rank, for it is far more frequently resorted to than any other mode of quickening labor. To show how common this practice has of late become, let me give some instances: At a meeting of one of the branch societies of the British Medical Association a member stated' that "he was 1 British Medical Journal, January 5, 1878, p. 17. VOL. XII. 5 in the habit of rupturing the membranes as soon as he arrived in every case of labor, and found this very useful." Another remarked "that at one time he thought the membranes were of some use, but he did not now believe it." Yet each of these statements was allowed to pass unchallenged. Again, a late writer,' in giving an analysis of eight hundred cases of labor, says: "I have never found any ill effects from rupturing the membranes when the os is the size of a shilling, but find that the child's head is a better wedge than the bag of liquor amnii. I am further convinced that much assistance can be rendered by the accoucheur gently dilating the os uteri with the finger during a pain, after the rupture of the membranes" Instead of sharply criticizing this unsound practice, a leader in one of the most influential British medical journals, to my surprise, warmly upheld it. "Dr. Matthews Duncan," it adds, "in his book on the 'Mechanism of Natural and Morbid Parturition,' has given experiments which go to show that the pressure necessary to rupture the membranes is about as great as that required to expel the child. It seems reasonable to suppose that if less force is expended in rupturing the membranes, there will be more in reserve to expel the child." Now all this I cheerfully grant, and if the chief end of the obstetrician be to deliver his patient quickly, the early rupture of the bag of waters is a means to the end. But if his chief end is to deliver his patient safely, then he must, other things being equal, let the membranes alone until the os has fully opened. And this advice holds with greater force in first labors, in which such rents of the cervix uteri far more frequently take place. This lesion may happen at any point in the rim of the os uteri, but when single the site of the fissure is usually on the side towards which the vertex presented, and it is therefore more often found on the left verge. When the rent is a double one, the cleft, according to my observation, usually runs across the cervix from left to right, splitting it into a fore-lip and a hind-lip. Apart from bleeding no immediate symptoms attend this lesion. The cervix is so lengthened out, bruised, and swollen by the passage of the child, and hangs down from the vaginal roof so limp, that a rent in its rim is not easily discoverable directly after labor. Such a lesion may, however, be suspected whenever an oozing, or even a flooding, keeps on, notwithstanding the womb is firmly contracted and the perineum uninjured. I have seen an alarming London Lancet, October 20, 1877, p. 569. 2 Ibid., November 3, 1877, p. 662. flooding happen from this cause, but this is rare, because, although the rent may extend beyond the line of junction with the vaginal roof, the utero-cervical artery, or circumflex branch of the uterine artery, from its own elasticity and from its loose connections with the parts, will usually stretch, and thus escape being torn across. The behavior of such a rent depends largely upon its site. If it be in the fore-lip or in the hind-lip of the cervix, or even if it cleave the cervix in two through the conjugate diameter, it will very generally heal up, and by the first intention. This fortunate result happens, because the greatest play of the womb being forward and backward, the fissure-line coincides with the line of the greatest uterine mobility. The lips of the wound, therefore, do not spread apart, but are kept together by the elastic compression of the vaginal walls. When, however, the rent is lateral, or it cleaves the cervix transversely, the fissure-line no longer coincides with the axis of motion, but crosses it. Also, in the up and down play of the womb, the hind-lip is liable to hitch on the sacrum and be forced away from its fellow. Hence these two sets of uterine movements tend to separate the flaps and keep the wound from healing. When immediate union takes place, nothing untoward happens besides the primary symptom of bleeding. But if the wound is a deep one, and slow to heal up, or it gapes open and fails to close, symptoms of perimetritis, or of parametritis, are, in my experience, pretty sure to show themselves. On the third or the fourth day the woman will complain of pain in that broad ligament, which corresponds to the torn side of the cervix. This pain is often ushered in by a chill. Occasionally, if the rent be a double one, after the inflammation has subsided on one side, it will take a fresh start on the other. The pulse keeps up and the body-heat high. Sometimes pain will be absent, and the inflammatory symptoms latent, yet the convalescence will be slow, unaccountably so, unless firm pressure be made in each iliac fossa, when the woman will flinch. By retarding the process of involution such inflammations keep the womb bulky, make the lochia too abundant, and delay the convalescence. If the rent heals up the woman's health will in time become re-established; but should no union take place, she will never be the same woman that she was before her labor. When she leaves her bed she may complain of a sense of weight in the pelvic regions, of backache, of a constant tired feeling, of loss of sexual desire, of pain during coition, or of a show following it. Her linen. will be stained and stiffened by an abundant leucorrhoeal discharge. The menses will be profuse, and the intervals between them shorter. In time the nervous system will become deranged. The woman loses sleep, and gets to be a complaining and an hysterical creature-perhaps, indeed, a confirmed invalid. Sometimes lactation will stave off these symptoms, by keeping the menses in check, and by its derivative action on the blood circulating in the womb. But as soon as the child is weaned, or the menses reappear, the woman will begin to complain. Now what has happened to produce all this turmoil? The rent in the cervix has not healed up, and its flaps have spread apart and curled over like a split celery-top, exposing the cervical canal. Chafed by constant attrition on the posterior vaginal wall, the now unshielded lining membrane of this canal begins to shed its epithelium faster than it can be replaced, and becomes raw. Involution is arrested, and the heavy womb, having lost its vaginal prop either sags down or flops over backward. Then losing its angle of attachment to the vagina, it comes to lie more like the stopper of a bottle-that is, more in the axis of the vagina. The male organ must now impinge, not as before, on the side of the cervix, or below it, but directly into the split and gaping os uteri, robbing it of its basement membrane and epithelium. The countless loops of nervelets and blood vessels which form the villi are thus left naked. Their exposure begets an irritation which attracts an undue flux of blood to the cervix. The swollen mucous crypts and submucous tissues of the cervical canal push out before them the lining membrane, which thus becomes everted like the conjunctiva in ectropium. The constant fretting of the unprotected nerve filaments excites local or reflex pains. Or perhaps, nature having tried her hand at a tardy cure, a nerve imprisoned in a dense mass of cicatricial tissue is unduly pinched, and its outcries aid in keeping up the mischief. That this lesion is frequent, and that it is an important factor in the production of uterine disorders, witness the testimony of various writers. Dr. P. F. Mundé states that of those women applying to him for treatment 5.6 per cent. exhibit lacerations of the cervix. Dr. H. T. Hanks puts the average at 8.4 per cent.; Dr. Montrose A. Pallen "at fully 40 per cent." Dr. W. H. Baker at 10 per cent. My own experience at the Dispensary for the Diseases of Women at the University of Pennsylvania would lead me to infer, that about one out of every six women suffering from uterine trouble has an ununited laceration of the cervix. As another 1 New York Medical Record, 1876, p. 823. 2 Boston Medical and Surgical Journal, Sept. 20, 1877. |